Workers’ Compensation / Public Disability Benefit Questionnaire

Justification for Non-Substantive Changes for Form SSA-546

Workers’ Compensation / Public Disability Benefit Questionnaire

20 CFR 404.408

OMB No. 0960-0247

Background

Section 224 of the Social Security Act, as amended, authorizes us to collect workers’ compensation (WC) and public disability benefit (PDB) information to determine the effect on the Social Security disability insurance benefits.

The Social Security Administration (SSA) uses Form SSA-546 to obtain WC/PDB information. The paper form is used in the disability interview when we are unable to collect information electronically on the Modernized Claims System (MCS) application screens. Currently, the paper and PDF versions of this form include a signature requirement.

SSA recently reassessed the need for the respondent’s signature on this form and determined that we no longer require it. Therefore, we are removing the signature requirement from this form.

Revision to the Information Collection

• Change #1: SSA is removing the signature requirement from Form SSA-546.

Justification #1: We reassessed the need for a wet signature on this form and determined we no longer require it. Therefore, we will no longer ask respondents to sign this form prior to submitting it to SSA.

• Change #2:  We are replacing the Penalty of Perjury Statement with a Penalty of Perjury Warning: Anyone who knowingly makes or causes to be made a false statement or representation of material fact for use in determining a payment under the Social Security Act, or knowingly conceals or fails to disclose an event with an intent to affect an initial or continued right to payment, or submits or causes to be submitted any false statement or document knowing the same to contain any misrepresentation of material fact, commits a crime punishable under Federal law by fine, imprisonment, or both, and may be subject to administrative sanctions.

Justification #2:  The Penalty of Perjury Statement is directly connected to the signature and needs to be removed since a signature is no longer required. However, to maintain the intent of that statement, it will be replaced with a Penalty of Perjury Warning.

• Change #3: We are revising the PRA statements on this collection.

Justification #3: We are revising the PRA statements to reflect our current boilerplate language.  The current language, which dates back to the last reprint of the form, is now outdated.

• Change #4: We are revising the Privacy Act Statements on this collection.

Justification #4: SSA’s Office of the General Counsel is conducting a systematic review of SSA’s Privacy Act Statements on agency forms. As a result, SSA is updating the Privacy Act Statements on this collection.

After OMB approves the signature removal for this form, we will implement the new version of the form that clarifies that we no longer require a signature by removing the signature block.

This action will not affect the public reporting burden.